Provider Demographics
NPI:1598329500
Name:WAGSTER, ADRIENNE KATHLEEN
Entity type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:KATHLEEN
Last Name:WAGSTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 JACKSON WALK PLZ
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-3008
Mailing Address - Country:US
Mailing Address - Phone:731-421-6950
Mailing Address - Fax:
Practice Address - Street 1:101 JACKSON WALK PLZ
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3008
Practice Address - Country:US
Practice Address - Phone:731-421-6950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-24
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7221235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty